What is the frequency of nerve injuries associated with acetabular fractures?

Salvage of Iatrogenic Sciatic Nerve Injury Caused by Operatively Treated Acetabular Fractures: Two Cases and Literature Review

BACKGROUND

While sciatic nerve injury has been described as a complication of acetabular fractures, iatrogenic nerve injury remains sparsely reported. This study aims to assess iatrogenic sciatic nerve injuries occurring during acetabular fracture surgery, tracking their neurological recovery and clinical outcomes, and investigating any correlation between recovery and the severity of neurologic injury to facilitate physicians in providing prediction of prognosis.

CASE PRESENTATION

We present two cases of male patients, aged 56 and 22, who developed sciatic palsy due to iatrogenic nerve injury during acetabular fracture surgery. Iatrogenic sciatic nerve injury resulted from operatively treated acetabular fractures. Surgical exploration, involving internal fixation removal and nerve decompression, successfully alleviated symptoms in both cases postoperatively. At the latest follow-up, one patient achieved full recovery with excellent function, while the other exhibited residual deficits at the L5/S1 root level along with minimal pain.

CONCLUSION

Sciatic nerve injury likely stemmed from reduction techniques and internal fixation procedures for the posterior column, particularly when performed with the hip flexed, thereby placing tension on the sciatic nerve. Our case reports underscore the significance of liberal utilization of electrophysiologic examinations and intraoperative monitoring for the prediction of prognosis. Surgical exploration, encompassing internal fixation removal and nerve decompression, represents an effective intervention for resolving sciatic palsy, encompassing both sensory neuropathy and motor symptoms.

Nonoperative Management of Both Column Acetabular Fracture and Protrusio Acetabuli in a Pregnant Patient: A Case Report

CASE

We present a case of a 39-year-old woman at 23 weeks gestation who sustained traumatic both-column acetabular fracture and protrusio acetabuli, managed with initial traction and delayed total hip arthroplasty (THA) until after cesarean section delivery.

CONCLUSION

Initial skeletal traction with subsequent delayed THA may be a viable treatment option in select pregnant female patients who sustain both-column acetabular fractures. Interdisciplinary collaboration is necessary to optimize maternal-fetal health and provide patient education of procedural risk to enable informed decision making.

Incidence, risk factors, and prognosis of sciatic nerve injury in acetabular fractures: a retrospective cross-sectional study

PURPOSE

This study aimed to investigate the incidence, risk factors of the sciatic nerve injury in patients with acetabulum fractures and assess its prognosis.

METHODS

A retrospective cross-sectional review was conducted on 273 patients with acetabulum fractures who were treated between January 1st, 2017, and December 30th, 2019. The medical records and radiographs of these patients were analyzed.

RESULTS

The overall nerve injury rate was 7.7% (21 of 273 cases), with 3.1% (8 of 273 cases) occurring because of the initial injury and 12.8% (13 of 101 cases) as post-operative complications. Among those with nerve injuries, 95.2% (20 of 21 cases) were males and the average age of the patients was 31.5 (SD 9.5) years. The most common mechanism of injury was motor vehicle collisions with 55.7% (152 of 273 cases), and the most common fracture pattern associated with nerve injury was posterior column and posterior wall fracture with 31.6% (6 of 21 cases). Hip dislocation was found in 16.5% (14 of 21 cases) of patients with nerve injury. The Kocher Langenbeck approach was the most common approach used for patients with post-operative nerve injury, and the prone position was significantly associated with sciatic nerve injury during the operation. Of all patients with nerve injury, 52% (11 of 21 cases) had fully recovered, 29% (6 of 21 cases) had partially recovered, and 19% (4 of 21 cases) had no improvement. The average follow-up was 15 months.

CONCLUSION

This study emphasizes the incidence of sciatic nerve injuries in individuals with acetabulum fractures and highlights key risk factors, including hip dislocation, posterior column, and posterior wall fractures. It is noteworthy that the Kocher Langenbeck approach and the prone position may contribute to iatrogenic nerve injuries. Encouragingly, over half of the patients who suffered nerve injuries achieved full recovery, while nearly one-third experienced partial recovery. These findings underscore the vital significance of recognizing and addressing these risk factors in clinical practice.

Outcomes of the Modified Stoppa Approach in Acetabular Fracture Management: Incidence of Nerve Injuries

Objectives

Displaced acetabular fractures are complex injuries that necessitate precise surgical intervention. Obturator nerve injuries occur in approximately 2% of cases. The modified Stoppa approach, offering enhanced exposure of the quadrilateral plate, has gained attraction as an alternative technique for anterior acetabular fractures. However, its proximity to the obturator nerve poses a risk of iatrogenic injury. This study aimed to investigate the incidence of nerve injuries and functional outcomes in patients undergoing the modified Stoppa approach for traumatic acetabular fractures.

Methods

This retrospective study involved 86 patients with anterior column fractures, whose data were prospectively collected. The fractures were treated using the modified Stoppa approach. Exclusion criteria were pathological fractures, alternative surgical approaches, prior nerve injuries, hip issues, refusal to participate, or inadequate follow-up. Data collection involved pre-operative imaging, thorough post-operative neurological assessments, and post-operative radiographic evaluation. Functional outcomes were assessed using the Harris Hip Score (HHS).

Results

Most patients were male (n=54) with a mean age of 40±17.3 years. Post-operative infection occurred in six cases, with resolution in four through antibiotics and two necessitating device removal. Obturator nerve damage was detected in 14 patients, comprising nine traumatic and five iatrogenic cases. During the follow-up, symptoms improved in all patients, except for the four patients with iatrogenic nerve damage.

Conclusion

Traumatic nerve injuries generally heal naturally over time. In contrast, iatrogenic injuries have a less optimistic prognosis, potentially resulting in lasting neurological deficits.

Sciatic and tibial neuropathies

The sciatic nerve is the body's largest peripheral nerve. Along with their two terminal divisions (tibial and fibular), their anatomic location makes them particularly vulnerable to trauma and iatrogenic injuries. A thorough understanding of the functional anatomy is required to adequately localize lesions in this lengthy neural pathway. Proximal disorders of the nerve can be challenging to precisely localize among a range of possibilities including lumbosacral pathology, radiculopathy, or piriformis syndrome. A correct diagnosis is based upon a thorough history and physical examination, which will then appropriately direct adjunctive investigations such as imaging and electrodiagnostic testing. Disorders of the sciatic nerve and its terminal branches are disabling for patients, and expert assessment by rehabilitation professionals is important in limiting their impact. Applying techniques established in the upper extremity, surgical reconstruction of lower extremity nerve dysfunction is rapidly improving and evolving. These new techniques, such as nerve transfers, require electrodiagnostic assessment of both the injured nerve(s) as well as healthy, potential donor nerves as part of a complete neurophysiological examination.

Management of Obturator Vessel Hemorrhage by Pubic Ramus Osteotomy During Acetabular Fixation-A Technical Trick

SUMMARY

It is known that hemorrhage from pelvic ring and acetabular fractures can cause hemodynamic instability. Methods to improve visualization and thus management of bleeding vessels are not commonly described. This report highlights techniques to manage hemorrhage from a retracted obturator vein during the definitive fixation of a complex acetabular fracture. After uncomplicated modified Stoppa anterior intrapelvic approach, abrupt and profuse bleeding was encountered from the distal end of a lacerated obturator vein, which had retracted into the obturator foramen. With unsuccessful attempts to achieve hemostasis, a superior pubic osteotomy was performed which allowed excellent visualization of the bleeding vein and ligation. It must be emphasized that the surgeon attempted all these other measures before performing an osteotomy. This technical trick contributes to the overall knowledge as a means of achieving emergent hemostasis associated with distal obturator vessel hemorrhage, a well described risk in complex acetabular fractures.

Rates and risk factors of complications associated with operative treatment of pelvic fractures

PURPOSE

Post-operative complications following fixation of pelvic fractures can lead to mortality and increased morbidity. Available literature regarding complications is heterogeneous and knowledge on risk factors is limited. This study aims to identify the most common post-operative complications and their possible risk factors following pelvic fracture surgery.

METHODS

A retrospective cohort study was performed in two level-1 trauma centers in the Netherlands between January 2015 and January 2021. Included patients were all adult patients (≥ 18 years) with an operatively treated pelvic fracture (pelvic ring and/or acetabular fractures). Post-operative complications included surgical site infections (SSI), material-related complications, neurological complications, malunion/non-union and performed reoperations. A forward stepwise multivariable logistic regression analysis was used to identify any risk factors associated with these complications.

RESULTS

Complications occurred in 55 (24%) of the 233 included patients. SSI's were most common, occurring in 34 (15%) patients. Duration of surgery (odds ratio 1.01 per minute, 95% confidence interval 1.00-1.01) and obesity (odds ratio 1.10 per BMI point, 95% confidence interval 1.29-7.52) were independent risk factors for development of SSI. Less common post-operative complications were material-related complications (8%) and neurological damage (5%).

CONCLUSION

Limiting operation time by using less invasive and less time-consuming surgical approaches may reduce the risk of SSI. More awareness and post-operative screening for early signs of SSI is mandatory, especially in obese patients. Future research should include large prospective patient cohorts to determine risk factors for other post-operative complications associated with pelvic fracture surgery.

Risk of Postoperative Sciatic Nerve Palsy After Posterior Acetabular Fracture Fixation: Does Patient Position Matter?

OBJECTIVES

To determine whether the prone or lateral position is associated with postoperative sciatic nerve palsy in posterior acetabular fracture fixation.

DESIGN

Retrospective cohort study.

SETTING

Three Level I trauma centers.

PATIENTS

Patients with acetabular fractures treated with a posterior approach (n = 1045).

INTERVENTION

Posterior acetabular fixation in the prone or lateral positions.

OUTCOME MEASUREMENTS

The primary outcome was the prevalence of postoperative sciatic nerve palsy by position. Secondary outcomes were risk factors for nerve palsy, using multiple regression analysis and propensity scoring.

RESULTS

The rate of postoperative sciatic nerve palsy was 9.5% (43/455) in the prone position and 1.5% (9/590) in the lateral position ( P < 0.001). Intraoperative blood loss and surgical duration were significantly higher for patients who developed a postoperative sciatic nerve palsy. Subgroup analysis showed that position did not influence palsy prevalence in posterior wall fractures. For other fracture patterns, propensity score analysis demonstrated a significantly increased odds ratio of palsy in the prone position [aOR 7.14 (2.22-23.00); P = 0.001].

CONCLUSIONS

With the exception of posterior wall fracture patterns, the results of this study suggest that factors associated with increased risk for postoperative sciatic nerve palsy after a posterior approach are fractures treated in the prone position, increased blood loss, and prolonged operative duration. These risks should be considered alongside the other goals (eg, reduction quality) of acetabular fracture surgery when choosing surgical positioning.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

[Management of complications of acetabular fractures]

Surgical treatment of acetabular fractures represents a special challenge in the field of trauma surgery. Complications are mostly due to the trauma itself or are iatrogenic. The handling and strategy to overcome complications in acetabular surgery are oriented towards the type of complication and the time of occurrence. Generally, a differentiation is made between early perioperative complications and late complications. The present article describes the most frequent complications during the surgical treatment of acetabular fractures, discusses the various treatment options based on individual case examples and gives differentiated recommendations to overcome the complications. The treatment concept should initially comprise a comprehensive primary prophylaxis to prevent complications. In cases of early perioperative complications, e.g. postoperative wound infections, hemorrhage or incorrect implant positioning, rapid and systematic surgical revision should be performed. In contrast, the treatment of late complications (e.g. implant associated failures, secondary osteoarthrosis of the hip, periarticular heterotopic ossification, non-unions and late infections) depends on the clinical and functional condition of the patient. In symptomatic elderly patients secondary total hip replacement is usually a valid option, whereas younger patients with late complications can be candidates for joint-preserving procedures. The management of complications in acetabular surgery regularly requires intense patient guidance as well as thorough clarification and should be performed in specialized centers.

Incidence of traumatic sciatic nerve injury in patients with acetabular fractures and factors affecting recovery: a retrospective study

BACKGROUND

Reports on traumatic sciatic nerve injury associated with acetabular fracture are rare. In this study, we investigated the demographics of these injuries, their clinical characteristics, management, and factors potentially influencing neurological recovery.

METHODS

We retrospectively reviewed all patients diagnosed to have acetabular fracture at our trauma center between January 2014 and June 2021. Data on patient demographics, characteristics of sciatic nerve injury, neurological recovery, factors potentially influencing neurological recovery were analyzed.

RESULTS

Eighteen patients (bilateral in one case) met the diagnostic criteria. All these injuries involved the posterior wall or posterior column, and most patients had posterior dislocation of the hip joint. Four of the 19 sides with traumatic sciatic nerve injury involved the common peroneal nerve division and 15 involved both the common peroneal and tibial nerve divisions. Seventeen patients (18 sides) underwent intraoperative nerve exploration, which revealed abnormalities in 7 sides and no obvious abnormality in 11 sides. At the last follow-up, 10 sides (52.6%) had complete recovery and 9 (47.4%) had partial recovery; the difference was statistically significant between those with or without abnormal nerve damage during exploration (P = 0.046). Linear regression analysis showed that a nerve abnormality detected intraoperatively was a predictor of nerve recovery (P = 0.009). The mean recovery time was significantly longer for partial recovery than for complete recovery (13.78 months vs. 6.70 months; P = 0.001).

CONCLUSIONS

All the injuries in this series involved the posterior wall or posterior column, and most patients had posterior dislocation of the hip joint. Damage to the common peroneal nerve division was more severe than that to the tibial nerve division preoperatively. However, the degree of recovery of the common peroneal division was not worse than that of the tibial division. There was a relationship between the degree of neurological recovery and whether there was an abnormality at the time of intraoperative nerve exploration. Patients with partial recovery took longer to recover.

Incidence of Traumatic Sciatic Nerve Injury in Association with Acetabular Fracture: A Retrospective Observational Single-Center Study

Purpose

Patients and Methods

Results

Conclusion

Evaluation and Management of Posterior Wall Acetabulum Fractures

Posterior wall acetabulum fractures typically result from high-energy mechanisms and can be associated with various orthopaedic and nonorthopaedic injuries. They range from isolated simple patterns to multifragmentary with or without marginal impaction. Determination of hip stability, which can depend on fragment location, size, and displacement, directs management. Although important in the assessment of posterior wall fractures, CT is unreliable when used to determine stability. The dynamic fluoroscopic examination under anesthesia (EUA) is the benchmark in assessment of hip stability, and fractures deemed stable by EUA have good radiographic and functional outcomes. In fractures that meet surgical criteria, accurate joint reduction guides outcomes. Joint débridement, identification and elevation of impaction, and adjunctive fixation of posterosuperior and peripheral rim fragments along with standard buttress plate fixation are critical. Complications of the fracture and surgical fixation include sciatic nerve injury, posttraumatic osteoarthritis, osteonecrosis of the femoral head, and heterotopic ossification. Although accuracy of joint reduction is paramount for successful results, other factors out of the surgeon's control such as comminution, femoral head lesions, and dislocation contribute to poor outcomes. Even with anatomic restoration of the joint surface, good clinical outcomes are not guaranteed and residual functional deficits can be expected.

Acetabular Fractures with Central Hip Dislocation: A Retrospective Consecutive 50 Case Series Study Based on AO/OTA 2018 Classification in Midterm Follow-Up

Introduction

Management of acetabular fractures is challenging, especially when a medial acetabular fracture is complicated by central hip dislocation. We retrospectively investigated the clinical outcome and risk factors of secondary hip osteoarthritis requiring total hip arthroplasty after the surgical treatment of acetabular fractures with central hip dislocation.

Materials and Methods

The medical records of all patients who had acetabular medial wall fractures with central hip dislocation treated with open reduction and internal fixation by a single surgeon between January 2015 and June 2017 were reviewed. Surgical reduction was performed with the modified Stoppa with/without the Kocher-Langenbeck (KL) approach. Patients were followed for a minimum of three years, and the Majeed scoring system was used for functional evaluation. Multivariate logistic regression analysis was used to assess the association of patients' characteristics with the likelihood of advanced posttraumatic arthritis developing with conversion to total hip arthroplasty.

Results

Fifty patients were included in this study, with disease classified as AO/OTA 2018 62B/62C. Thirty-five patients (70%) had good or excellent Majeed pelvic scores. Eleven patients (22%) eventually received total hip arthroplasty because of end-stage posttraumatic arthritis. Three risk factors identified for total hip arthroplasty were male sex, initial marginal impaction, and sciatic nerve injury. Kaplan-Meier survivorship analysis estimated that the cumulative probability of free-from-end-stage arthritis was 78% (95% confidence interval, 73%–90%) at the 5-year follow-up.

Conclusion

Surgical fixation with the modified Stoppa and the KL approach for acetabular medial wall fractures with central hip dislocation is an effective approach with a satisfactory functional outcome. A prodromal factor was marginal impaction concomitant with articular damage. The trauma of high axial loading and the occupational distribution (males performing heavy manual labor and heavy lifting) with preoperative sciatic nerve injury increased the odds of developing end-stage arthritis.

Rehabilitative management of pelvic fractures: a literature-based update

A comprehensive rehabilitation program is required after Pelvic Fracture (PF). In a PF rehabilitation setting an effective treatment and a proper management of complications is supplied by an appropriate and reliable clinical assessment. In this literature-based update, we search on MEDLINE, EMBASE, and the Cochrane Database of Systematic reviews to find articles, scientific society guidelines and practioners experiences defining the rehabilitative management of clinically PF outcomes. Based on literature evidences and expert opinions, a set of key topics was collated to generate advices and recommendations to put into daily practice. Even if there are no high-quality evidence for rehabilitative interventions after PF in terms of duration and modality of therapy, rehabilitation setting, care pathways, and long-term functional outcomes, it is strongly recommended an early multidisciplinary intervention to improve recovery from PF.

Complications of surgical approaches for osteosynthesis treatment of acetabular fractures: Analysis of pitfalls and how to avoid them

BACKGROUND

Fractures of the acetabulum are rare injuries. The indication for surgical stabilization depends on the grade of instability and dislocation. Exact knowledge of the different possible surgical approaches is essential for the planning of the surgical treatment. Both, knowledge of anatomical structures and possible risks of the different approaches, are important.

METHODS

Over a period of 15 years, we analyzed all patients with acetabular fractures, treated in our Level I Trauma Center with special interest in surgical and approach-related complications. Based on our complication rates, we describe the used different surgical approaches and the accessible anatomical structures respectively. Finally, we focus on strategies to reduce the risk of approach-related complications in acetabular surgery.

RESULTS

Between January 2003 and December 2017, 523 patients with an acetabular fracture were treated in our Tertiary Referral Hospital. Of these, 101 patients had at least one complication, resulting in an overall complication rate of 19.3%. 296 patients underwent surgical treatment of the acetabular fracture, while 227 patients were treated non-operatively. Surgically treated patients had a significantly higher complication rate of 21.2% (63/296) compared to conservatively treated patients with a complication rate of 16.7% (38/227). Neurovascular and thromboembolic adverse events were the most often complications.

CONCLUSIONS

Patients with acetabular fractures are at a high risk for different kind of complications. The most common risks are neuro-vascular and thromboembolic incidents. The risk of getting a complication is increased in surgically treated patients, therefore both the indication for surgical treatment and the surgical approach should be carried out carefully, including individual patient parameters and fracture types as well as the surgeons expertise.

[Reconstruction of a fracture of the posterior acetabular wall with Pipkin fracture and lesion of the sciatic nerve after dorsal hip dislocation]

A 50-year-old male suffered a crash landing while paragliding and sustained a posterior dislocation of the hip with a Pipkin fracture type 4 (fracture of the posterior acetabular wall and Pipkin fracture type 2) and a lesion of the sciatic nerve. After primary treatment in an external hospital, the patient was transferred to this hospital 4 days following the trauma. An operative stabilization of the acetabular fracture and the Pipkin fracture was performed using a trochanter flip osteotomy. Despite a large central defect of the femoral head it was decided to attempt a reconstruction. Following fixation of the Pipkin fragment an autologous bone graft harvested from the intertrochanteric region was used to fill the defect. Subsequently, a collagen matrix was applied onto the filled defect and a perineural adaptation of the sciatic nerve was performed.

Solutions for failed osteosynthesis of the acetabulum

Osteosynthesis of the acetabulum is complex and requires very careful planning and preoperative preparation. The goal is to achieve anatomical reduction without steps or gaps in the articular surface. If it has not been possible to achieve an optimal reconstruction, one has to consider whether it makes sense to carry out reosteosynthesis or revise the fixation. The risk of infection, heterotopic ossification, avascular necrosis of the femur and cartilage damage is much higher than with the primary procedure. Often, especially in older patients, it may make more sense to achieve fracture union and to implant a total hip prosthesis in due course. In younger patients, every attempt should be made to achieve optimum anatomical reduction and this may mean consideration of reosteosynthesis after careful planning and counselling of the patient. If reosteosynthesis is considered adequate imaging including a postoperative CT is essential as part of the planning. This article looks at the possible solutions for failed osteosynthesis of the acetabulum.

Risks and Strategies to Avoid Approach-Related Complications During Operative Treatment of Pelvic Ring or Acetabular Fractures

Injuries of the pelvic ring or the acetabulum are either to be found in young patients with high energy trauma mechanisms or in geriatric patients after simple falls with very low impact energy. The indication for surgical stabilization is given by the grade of instability. Exact knowledge of the different possible surgical approaches is essential for the planning of the surgical treatment. Both, knowledge of reachable anatomical structures and possible risks of the different approaches are important. In this review, we summarize the standard surgical approaches to the pelvic ring and to the acetabulum. We describe the reachable anatomical structures for each approach, approach-related pitfalls, and we focus on strategies to reduce approach-related complications.

Nerve Injury With Acetabulum Fractures: Incidence and Factors Affecting Recovery

OBJECTIVES

To determine factors associated with nerve injury after acetabulum fracture and to evaluate recovery and outcomes.

DESIGN

Retrospective cohort study.

SETTING

Level 1 trauma center.

PATIENTS AND PARTICIPANTS

Nine hundred seventy-five skeletally mature patients with acetabulum fracture.

INTERVENTION

Operative and nonoperative management.

MAIN OUTCOME MEASUREMENTS

Nerve injuries, categorized as traumatic or iatrogenic, recovery (none, partial, or complete), and patient-reported functional outcomes with the Musculoskeletal Function Assessment (n = 353, 36.2%).

RESULTS

Thirty-two patients (3.3%) experienced nerve injury with 24 (78%) resulting from trauma and 23 with an associated posterior hip dislocation. Eight injuries (25%) were iatrogenic. Thirty-one (97%) occurred in patients with operative fractures (n = 738). The most common fracture pattern associated with nerve injury was transverse posterior wall (31% of injuries). Obesity was more common in patients with nerve injuries (59% vs. 30% in those without nerve injury (P = 0.001), but was not related to age or sex. Sixty-five percent of sciatic nerve injuries were to the common peroneal division only, while none were isolated to the tibial division. All iatrogenic injuries occurred after the ilioinguinal approach (P < 0.001). Overall, 50% experienced partial nerve recovery and 22% had complete recovery. However, 24% of patients with sciatic or common peroneal injuries had no recovery. Thirty-three percent of tobacco smokers experienced no recovery (vs. 26% of nonsmokers). Average Musculoskeletal Function Assessment scores for patients with nerve injuries was 32, similar to those without (33).

CONCLUSIONS

Posterior acetabulum fracture dislocations are associated with traumatic nerve injury, although 25% of nerve injuries were iatrogenic. Nerve injuries are more common in obese patients. More than one-quarter of patients had no recorded nerve recovery.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Decision-making, therapy, and outcome in lateral compression fractures of the pelvis - analysis of a single center treatment

Background

Pelvic lateral compression fractures are the most stable of the unstable fractures. Therefore, decision making regarding operative or non-operative therapy is still a matter of debate.

Methods

Factors, influencing decision making for therapy, were explored based on prospectively collected register data of a single Level-1 trauma center. The analysis included epidemiological records such as age and gender, and injury characterizing parameters such as degree of displacement and the Injury Severity Score (ISS). In-hospital mortality and complications served as short-term outcome variables. After matching for relevant confounders, long-term results were compared between operatively and non-operatively treated patients, evaluating the Merle d’Aubigne and the EQ. 5D-3 L scores.

Results

Over an 11-year period (2004–14), 134 patients suffered from lateral compression fractures out of 567 pelvic fractures (33%). After excluding patients with clear indications for operation (complex pelvic fractures and pubic symphysis ruptures) and pediatric fractures, 114 patients could be included in the analysis. Sixty-one patients were treated conservatively (54%), 53 with an operation (46%). The operated patients were younger (43.7 vs 58.3 years), had higher ISS (19.9 vs 15.5 points) and fracture displacements (2.3 vs 4.9 mm) (p < 0.001 for all). The length of hospital stay was shorter in the conservatively treated group (12.7 vs 17.3 days, p < 0.02). Although the types of complications were different, the incidence was not. The mortality was less in the operated group (1.9% vs. 6.6%), however, a logistic regression analysis showed that only the ISS was an independent risk factor, but not the type of therapy. Merle d’Aubigne and EQ. 5D-3 L scores were not different in the matched cohorts.

Conclusion

Decision-making for operative therapy was favored in severely injured young patients with high displacement. However, short- and long-term outcomes showed no difference between operatively and non-operatively treated patients.

Trial registration

DRKS, no. 00000488. Registered 14th July 2010 - Retrospectively registered

In-hospital mortality of pelvic ring fractures in older adults now and then: A pelvic registry study

AIM

With the predicted demographic change, the treatment of geriatric patients will become a major issue for health systems worldwide. The majority of pelvic ring fractures occur in older adults, and their treatment might be associated with a distinct mortality. Herein, we analyzed the data of 5665 patients with pelvic ring fractures aged ≥60 years included in the German Pelvic Trauma Registry from 1991 to 2013.

METHODS

The data were collected prospectively, multicentrically in hospitals participating in the German Pelvic Trauma Registry. Demographic data were retrospectively analyzed, stratified for age, sex, type of injury, mode of therapy, injury severity score (ISS) and mortality.

RESULTS

The overall mortality decreased over the 22-year study period from 9.3% to 3.8% (P < 0.05), whereas the median ISS significantly increased. During the observation period, mortality was higher in patients with type B and, particularly, type C fractures when compared with patients with type A fractures. Mortality rates of patients aged >80 years did not significantly differ from those aged >60 or >70 years. Male patients showed a significantly higher mortality compared with female patients, as well as a significantly higher median ISS. The mortality rate of patients with surgically-treated type C fractures decreased over the study period from 35.7% to 6.9% (P < 0.05).

CONCLUSIONS

Over the past two decades, the mortality of older patients after pelvic ring fractures has significantly decreased. The higher overall mortality rate of male patients might mainly be accounted for by the relatively higher fraction of type C fractures and a higher ISS. Geriatr Gerontol Int 2019; 19: 24-29.

Use of Spring Plates in Fixation of Comminuted Posterior Wall Acetabular Fractures

OBJECTIVES

Surgical management of comminuted posterior wall acetabular fractures with marginal fragments remains difficult. The purpose of this study was to evaluate the use of spring plates as adjunctive fixation in comminuted posterior wall acetabular fractures.

METHODS

A retrospective review of patients treated for posterior wall acetabular fractures with the use of customized spring plates as adjunctive fixation between 2000 and 2017 was performed. Patients were evaluated radiographically according to the grading criteria of Matta. Complications including subsequent revision surgery and hardware failure were recorded.

RESULTS

Fifty-two patients underwent surgical fixation of posterior wall acetabular fractures with the use of customized 3.5-mm spring plates combined with posterior buttress compression plating over the spring plates as definitive fixation. Mean follow-up was 13.9 months (range: 3-140 months). Forty-two patients had radiographic grades of excellent, with 6 good, 1 fair, and 3 poor. There were no hardware complications. Five patients underwent revision surgery, including 4 patients (7.7%) who underwent a total hip arthroplasty due to advanced arthritis.

CONCLUSIONS

The use of customized spring plates is a viable method of adjunctive fixation for comminuted posterior wall fractures with marginal fragmentation.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Injury of the obturator nerve in the modified Stoppa approach for acetabular fractures

INTRODUCTION

The modified Stoppa approach for acetabular fractures has become popular. However, the possibility of injury to the obturator nerve with this approach has not been sufficiently considered. We have experienced a case of nerve entrapment in severely displaced fractures. Therefore, we performed a retrospective study to: (1) evaluate the incidence of obturator nerve injury in the modified Stoppa approach for acetabular fractures; (2) analyze the relationship between the extent of displacement of the quadrilateral plate and injury to the obturator nerve.

HYPOTHESIS

We hypothesized that obturator nerve injury would be related to a marked medial displacement of the quadrilateral plate.

PATIENTS AND METHODS

We conducted a retrospective cohort study of 22 patients with acetabular fractures that were surgically treated with the modified Stoppa approach. The medial displacement of the quadrilateral plate was measured on a three-dimensional reconstruction image with the inlet view. Postoperative electrodiagnostic tests were performed based on clinical suspicion of neurological injury. Nerve injuries were divided into initial trauma or postoperative complication, and recovery of nerve function was evaluated. We identified the incidence of obturator nerve injury and analyzed the relationship between obturator nerve injury and medial displacement of the quadrilateral plate.

RESULTS

The incidence of obturator nerve injury was 2/22 (9.1%), and all injuries resulted from the initial trauma. The average displacement of the quadrilateral plate was 15.9±13.4mm. Patients were divided into two groups, using a displacement of 24mm as a cutoff point, identified using a receiver operating characteristic curve analysis. There were 16 patients in group 1 (<24mm) and 6 patients in group 2 (≥24mm). The incidence of obturator nerve injury from trauma was 0/16 (0%) in group 1 and 2/6 (33.3%) in group 2 (P=0.018).

CONCLUSIONS

No cases of postoperative obturator nerve injury were identified. Preoperative obturator nerve injury was more common in patients with a displacement of the quadrilateral plate≥24mm.

LEVEL OF EVIDENCE

IV, retrospective study.

Surgical results and factors influencing outcome in patients with posterior wall acetabular fracture

The purpose of this study was to evaluate the results of open reduction and internal fixation in a large series of posterior wall fractures of the acetabulum and to identify the factors that affect the outcomes in this case series. One hundred twenty-one patients who had undergone open reduction and internal fixation of a fracture of the posterior wall of the acetabulum were assessed at a mean of 53 months (range, 24-163) after surgery. The functional outcome was evaluated with use of the modified Merle d'Aubigne scoring system, the Harris Hip Score (HHS), and the Short Form-36 Health Survey (SF-36) questionnaire. Final follow-up radiographs were graded according to Matta's radiologic criteria. Patient, fracture, and radiographic variables were analyzed to identify possible associations with functional and radiographic outcome. The quality of fracture reduction on postoperative radiographs was anatomical in 115 hips (95.0%), satisfactory in 6 cases (5.0%), and unsatisfactory in none. Final modified d'Aubignè scores were excellent in 45 hips (40.2%), good in 52 (46.4%), fair in 7 (6.3%), and poor in 8 (7.1%). Mean HHS was 91.5±8.9 (48-100). The SF-36 scores were similar with respect to age and sex-matched norms, but physical domains in males remained lower in comparison with the normal population. The early reduction of an associated hip dislocation and quality of surgical reduction were strong positive predictors of functional and radiographic outcomes at follow-up, whereas associated injuries and the existence of pre-operative nerve palsy were negative predictors of patients' functionality. This study of surgically treated fractures of the posterior wall of the acetabulum has shown that functional and radiographic results are satisfactory in most patients, provided that prompt reduction of an associated hip dislocation and anatomical reduction of the fracture are carried out. Associated injuries and nerve lesions affect the final functional outcome.

The Anterior Intrapelvic Approach for Acetabular Fractures Using Approach-Specific Instruments and an Anatomical-Preshaped 3-Dimensional Suprapectineal Plate

OBJECTIVES

Anatomical acetabular plates the anterior intrapelvic approach (AIP) were recently introduced to fix acetabular fractures through the intrapelvic approach. Therefore, we asked the following: (1) Does the preshaped 3-dimensional suprapectineal plate interfere with or even impair the fracture reduction quality? (2) How often does the AIP approach need to be extended by the first (lateral) window of the ilioinguinal approach?

DESIGN

Observational case series.

SETTING

Two Level 1 trauma centers.

PATIENTS/PARTICIPANTS

Patients with unstable acetabular fractures in 2014.

INTERVENTION

Fracture fixation with anatomical-preshaped, 3-dimensional suprapectineal plates through the AIP approach ± the first window of the ilioinguinal approach.

OUTCOME MEASUREMENTS

Fracture reduction results were measured in computed tomography scans and graded according to the Matta quality of reduction. Intraoperative parameters and perioperative complications were recorded. Radiological results (according to Matta) and functional outcome (modified Merle d'Aubigné score) were evaluated at 1-year follow-up.

RESULTS

Thirty patients (9 women + 21 men; mean age ± SE: 64 ± 8 years) were included. The intrapelvic approach was solely used in 19 cases, and in 11 cases, an additional extension with the first window of the ilioinguinal approach (preferential for 2-column fractures) was performed. The mean operating time was 202 ± 59 minutes; the fluoroscopic time was 66 ± 48 seconds. Fracture gaps and steps in preoperative versus postoperative computed tomography scans were 12.4 ± 9.8 versus 2.0 ± 1.5 and 6.0 ± 5.5 versus 1.3 ± 1.7 mm, respectively. At 13.4 ± 2.9 months follow-up, the Matta grading was excellent in 50%, good in 25%, fair in 11%, and poor in 14% of cases. The modified Merle d'Aubigné score was excellent in 17%, good in 37%, fair in 33%, and poor in 13% of cases.

CONCLUSION

The AIP approach using approach-specific instruments and an anatomical-preshaped, 3-dimensional suprapectineal plate became the standard procedure in our departments. Radiological and functional early results justify joint preserving surgery in most cases.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Fucntional and Radiological Outcome of Surgical Management of Acetabular Fractures in Tertiary Care Hospital

PURPOSE

Acetabular fractures are mainly caused by trauma and the incidence is rising in developing countries. Initially these fractures were managed conservatively, due to lack of specialized and dedicated acetabulum surgery centres. Our aim is to study the radiological and functional outcomes of surgical management of acetabular fractures in tertiary care hospital.

MATERIALS AND METHODS

Total 50 patients were enrolled. The patients with acetabular fractures were enrolled between the years 2012 to 2014. Patients were evaluated clinically with Harris hip score (HHS) and radiologically with Matta outcome grading. The factors examined include age, gender, fracture pattern, time between injury and surgery, initial displacement and quality of reduction on the final outcome.

RESULTS

There were 34 males and 16 females. Mean age was 44.20±11.65 years while mean duration of stay was 9.28±2.36 days. Duration of follow-up was 24 months. Most common mechanism of injury was motor vehicle accident (n=37, 74.0%). Open reduction and internal fixation of fractures were performed using reconstruction plates. Mean HHS at 24 months was 82.36±8.55. The clinical outcome was acceptable (excellent or good) in 35 (70.0%) cases and not acceptable (fair or poor) in 15 (30.0%) cases. The radiological outcome was anatomical in 39 (78.0%) cases, congruent in 5 (10.0%) cases, incongruent in 6 (12.0%) cases.

CONCLUSION

Study results indicated that mechanism of injury, time between injury and surgery, initial degree of displacement and quality of reduction had significant effect on functional as well as radiological outcome.

Classifying, measuring and improving the quality of data in trauma registries: A review of the literature

INTRODUCTION

Globally, injury is a major cause of death and disability. Improvements in trauma care have been driven by trauma registries. The capacity of a trauma registry to inform improvements in the quality of trauma care is dependent upon the quality of data. The literature on data quality in disease registries is inconsistent and ambiguous; methods used for classifying, measuring, and improving data quality are not standardised. The aim of this study was to review the literature to determine the methods used to classify, measure and improve data quality in trauma registries.

METHODS

A scoping review of the literature was performed. Databases were searched using the term "trauma registry" and its synonyms, combined with multiple terms denoting data quality. There was no restriction on year. Full-length manuscripts were included if the classification, measurement or improvement of data quality in one or more trauma registries was a study objective. Data were abstracted regarding registry demographics, study design, data quality classification, and the reported methods used to measure and improve the pre-defined data quality dimensions of accuracy, completeness and capture.

RESULTS

Sixty-nine publications met the inclusion criteria. Four publications classified data quality. The most frequently described methods for measuring data accuracy (n=47) were checks against other datasets (n=18) and checks of injury coding (n=17). The most frequently described methods for measuring data completeness (n=47) were the percentage of included cases, for a given variable or list of variables, for which there was an observation in the registry (n=29). The most frequently described methods for measuring data capture (n=37) were the percentage of cases in a linked reference dataset that were also captured in the primary dataset being evaluated (n=24). Most publications dealing with the measurement of a dimension of data quality did not specify the methods used; most publications dealing with the improvement of data quality did not specify the dimension being targeted.

CONCLUSION

The classification, measurement and improvement of data quality in trauma registries is inconsistent. To maintain confidence in the usefulness of trauma registries, the metrics and reporting of data quality need to be standardised.

Pelvic Fractures in Children Results from the German Pelvic Trauma Registry: A Cohort Study

As pelvic fractures in children and adolescents are very rare, the surgical management is not well delineated nor are the postoperative complications. The aim of this study using the prospective data from German Pelvic Trauma Registry study was to evaluate the various treatment approaches compared to adults and delineated the differences in postoperative complications after pelvic injuries.Using the prospective pelvic trauma registry established by the German Society of Traumatology and the German Section of the Arbeitsgemeinschaft für Osteosynthesefragen (AO), International in 1991, patients with pelvic fractures over a 12-year time frame submitted by any 1 of the 23 member level I trauma centers were reviewed.We identified a total of 13,525 patients including pelvic fractures in 13,317 adults and 208 children aged ≤14 years and compared these 2 groups. The 2 groups' Injury Severitiy Score (ISS) did not differ statistically. Lethality in the pediatric group was 6.3%, not statistically different from the adults' 4.6%. In all, 18.3% of the pediatric pelvic fractures were treated surgically as compared to 22.7% in the adult group. No child suffered any thrombosis/embolism, acute respiratory distress syndrome (ARDS), multiorgan failure (MOF), or neurologic deficit, nor was any septic MOF detected. The differences between adults and children were statistically significant in that the children suffered less frequently from thrombosis/embolism (P = 0.041) and ARDS and MOF (P = 0.006).This prospective multicenter study addressing patients with pelvic fractures reveals that the risk for a thrombosis/embolism, ARDS, and MOF is significant lower in pediatric patients than in adults. No statistical differences could be found in the ratios of operative therapy of the pelvic fractures in children compared to adults.